Ambulance Services

Occupying a frontline position in our healthcare system, the ambulance service is subject to many pressures in the wider NHS. Our report into the ambulance service showed that ambulance resources are being overstretched because of cuts in primary care, mental health and care of the elderly.

Worst ever ambulance performance figures show NHS buckling under cuts

Ambulances travel further because of closed hospital units and wait with sick patients at overloaded A&E units.1 In the first three quarters of 2014-15 the number of people waiting longer than four hours in A&E increased by 13%.2 In February 2016, the NHS as a whole recorded its worst performance for the second month in succession.3 This crisis was reflected in NHS England’s graph of plunging ambulance response-time performance:Source NHS England 4

Ambulance trusts are required to send an ambulance within eight minutes to life-threatening Red 1 and Red 2 emergencies. By February 2016 the standard had been missed for Red 1 calls for nine months, with only 68% of calls receiving a response within 8 minutes. The standard for Red-2 calls was breached for the 25th consecutive month. At 60.3% this was the lowest performance since records began in 2012. 5 While several quality measures are also used to assess ambulance performance, these deteriorating figures show that the strategies that trusts use to cope with growing pressures are failing. Poor response times recently led to the London Ambulance Service (LAS) being rated “inadequate” and placed into special measures.6

Growing pressures

Funding cuts

The ambulance service not only deals with the effects of wider NHS underfunding, but has itself suffered a number of historic funding cuts. In 2014, North West Ambulance Service was forced to cut £13.8 million.7 East Midlands Ambulance Service implemented cuts of £6.2 million.8Forced to save £53m,in April 2011, LAS planned to cut 890 staff over five years.9 This year, the West Midlands Ambulance Service (WMAS) faces cuts of £11.7 million, following those of £8.8 million the previous year.10 Some ambulance trusts have also lost money because of changes to Clinical Commissioning Group paying arrangements:

“Over the last 5 years the income achieved for each incident has gone down by between 8.5% in urban areas, and 12.5% in rural areas and this has created a financial gap.”11

The toxic combination of rising demand, cuts and underfunding

Whilst finances have become tighter, demand has been rising for years at more than 5%.12 Failure to match this with funding has amounted to further cuts in real terms. Demand from NHS 111 for example, led to the South East Ambulance Service (SECAmb) making a loss of over £2.5m in 2014/15. With losses of £1.4m anticipated for 2015/ 16In 2014/15, the trust warned that the situation was “not sustainable.”13 The chairman of the College of Paramedics, Professor Andy Newton, said that demand has not been matched by numbers of staff and that nationally there are approximately 2,500 vacancies for paramedics. 14 Recently, Mark Docherty, Director of clinical commissioning and service development at WMAS told me that “even with increased training numbers, we will not cover the current vacancies in the next 10 years.”15In the meantime, demandhascontinued torise. The number of emergency telephone calls received by ambulance trusts in January 2016 was 821,937 - a 7.7 % increase on January 2015. 16

Failing coping strategies

The ambulance service managing demand

As well as managing demand on their own resources, ambulance trusts are paid by clinical commissioning groups (CCGs) to channel pressure away from A&E departments. They provide primary care, triage-down increasing numbers of calls by telephone and reduce the number of patients conveyed to hospital.17 Our report showed that in addition to these demand management schemes, ambulance trusts force crews to work to the point of exhaustion. They also use lesser-trained NHS crews and non-NHS ambulances in order to cope with a lack of capacity. The latest performance figures highlight the failure of these short-term fixes, used throughout the NHS in order to cope with cuts, underfunding and growing demand.

The use of lesser-trained crews, non- NHS staff and ‘efficiency’ drives

Many people assume that all ambulance staff are paramedics. Our report showed however, that in an attempt to meet response targets, under-resourced ambulance trustsrely on community first responders (volunteers equipped with defibrillators) and lesser-trained NHS staff. Unlike paramedics who are university trained, state-registered professionals, Emergency Care Assistants (ECAs) for example, receive a few weeks of training. Failure to provide lesser-trained staff with paramedic backup is placing lives at risk. One paramedic told us: “There appears to be a ‘they have stopped the clock’ mentality among senior management but patients have deteriorated and actually died while single responders end up having to initiate Basic Life Support ... Patients’ families are forced to watch as their loved ones deteriorate in front of them.” 18

Although evidence shows that most of the growth in emergency calls is the result of an ageing population, 19 cash-strapped ambulance trusts are forced to focus on reducing the number of unnecessary 999 calls. Peter Bradley, former LAS Chief Executive, stated: “Our whole plan is based on seeing fewer ambulances sent to calls and fewer patients transported to A&E. You can’t stop people ringing so we have to take responsibility to do something different with their calls ....” 20 One example of doing something different with patients calls, was SECAmb’s secret 111 demand management scheme. This intentionally delayed response to as many as 20,000 NHS 111 calls by ten minutes while they were re-triaged. An enquiry by NHS England into seven serious incidents including five deaths, condemned the practice.21 Whilst introduced without proper consultation or safety assessments, the scheme was arguably the logical conclusion of the growing emphasis on initiatives designed to do more with fewer resources in the NHS.

A senior manager at SECAmb that I spoke to in 2014 told me that even properly authorised and monitored demand management systems carry risks and that ‘triaging-down more than ten per cent of calls is considered to be unsafe.’ 22 Mark Docherty at WMAS has said that “Systems to reduce 999 demand generally don't work, and that is the experience around the world.” He told me that working without the aid of physical examination “telephone triage unfortunately in a time critical environment is inherently ‘difficult.” 23 Unsurprisingly, the numbers of people re-contacting ambulance services after discharge by telephone are consistently higher than those following face to face discharge. 24 Whilst using paramedics to discharge patients on the scene is safer, arbitrary quotas to reduce conveyance rates by a set percentage every year adds an additional element of risk. Mark Docherty states that it is safer to convey too many rather than too few patients to hospital. He added that “many people assume high non-conveyance is good, but I think we need to understand things better before we reach any conclusion.” 25 In February 2016 the non-conveyance rate was 38.3%, “the highest since April 2011.” 26 Despite this, as the performance figures show, the ambulance service is still struggling to cope.

Clearly, it is desirable to have efficient public services. A concentration on efficiency over the basic capacity to meet demand however, is false-economy that risks patient safety. The failure of short-term fixes to address lack of funding within the NHS is increasingly recognised. The Commons Public Accounts Committee recently identified a £22 billion ‘black hole’ in the funds necessary for the NHS to meet growth in patient demand and questioned whether the shortfall could be found from efficiency savings. 27 A Department of Health spokesperson suggested that savings could be made in the NHS by reducing the reliance on ‘rip off’ agency staff. 28

Whilst it is true that the use of costly agency workers only deepens funding problems, our report showed that the reliance on non NHS staff results from the failure of efficiency drives to make up for a fundamental lack of resources. We found that as a result, non-NHS crews are increasingly used to respond to even the most serious emergencies. Between January 2014 and April 2015, non-NHS ambulances responded to 313,661 emergencies. Of these, 139,086 were life-threatening. Three trusts stood out as larger users of private providers to attend emergencies: South Central (16%), South East (8%) and London (5%). 29 Worryingly, the South East Coast Ambulance Service (SECAmb) admitted to us that less than 2% of non-NHS ambulances have a professional paramedic onboard. 30 Crucially, A SECAmb director told me that “We would never have used the private sector if there hadn’t been such high levels of demand….” 31

Efficiency requires proper resourcing

Not only are efficiency drives unable to make up for cuts and lack of resources, but the improvements necessary to make trusts efficient, actually require additional resourcing. Mark Docherty told me that trusts often have to back up vehicles that don’t have a Paramedic. “To become efficient”, he said, trusts “need a higher level of Paramedics, which will need a cash boost to achieve, and arguably maintain.” 32

Laura Donnelly and Alastair Jamieson, Ambulance service gets £38 for every patient they don't take to hospital, The Telegraph, 27 Mar 2010, accessed from http://www.telegraph.co.uk/health/healthnews/7530895/ Ambulance-service-gets-38-for-every-patient-they-dont-take-tohospital.html

Response to my requests under the Freedom of Information Act (2000), March 2014

Ibid ref. 1

Ibid ref. 11

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